Optimizing donor site closure following bilateral breast reconstruction with abdominal-based free flaps

Polypropylene Mesh Complications in the Sublay Position After Abdominally Based Breast Reconstruction: Les complications des treillis de polypropylène en sous-couche après une reconstruction mammaire par voie abdominale

Introduction

Abdominal wall morbidity after microsurgical breast reconstruction is an important consideration for patients and surgeons. Previous studies are limited by multiple mesh locations or types. In this study, we evaluate specifically subfascial polypropylene mesh placement to determine a more definitive complication rate and basis for objective comparison.

Methods

A retrospective review was performed for patients undergoing microsurgical breast reconstruction at our institution by 3 surgeons from 2015 to 2018. All patients with sublay placement of polypropylene mesh were included. Patient demographics, medical comorbidities, type of reconstruction, and postoperative abdominal wall complications were recorded.

Results

A total of 114 flaps were performed on 81 patients who met the inclusion criteria. Of these, 48 were deep inferior epigastric artery (DIEP) flaps (42%), 43 were MS-2 TRAM flaps (37.8%), 20 were muscle sparing (MS-1) transverse rectus abdominus muscle (TRAM) flaps (17.5%), and 3 were free TRAM flaps (2.6%). Average follow-up was 392 days (range: 29-1191). Average body mass index was 30.7. No patients developed hernias. Two patients (2.5%) complained of post-operative bulges, neither of which required operative treatment. Two patients experienced superficial abdominal wall infection, one of which required admission and intravenous antibiotics. Ten patients (12.3%) had abdominal incision dehiscence, 3 of which required operative intervention. There were no cases of mesh exposure, contamination, or removal.

Conclusion

Polypropylene mesh is safe and effective, with subfascial placement resulting in low morbidity and low rates of bulge/hernia formation after microsurgical breast reconstruction. Consideration should be given to using polypropylene mesh for fascial repairs after microsurgical breast reconstruction, particularly in high-risk populations.

Comparison of Phasix, polypropylene, and primary closure of the abdominal donor site after bilateral free flap breast reconstruction: Long-term evaluation of abdominal hernia and bulge formation

BACKGROUND

Abdominal free flap harvest for breast reconstruction may result in significant morbidity in terms of hernias and bulges. Reinforcement of the donor site with mesh has been recommended to minimize the risk of hernias and bulges, but no studies exist evaluating the optimal type of mesh. Polypropylene has traditionally been used but the development of Phasix restorable mesh may be a reasonable alternative. Here, we compared the use of Phasix to polypropylene and primary closure and hypothesize that the former has lower rates of abdominal morbidity in the long term.

PATIENTS AND METHODS

A retrospective review of all patients undergoing bilateral free flap breast reconstruction from the abdomen was performed while patients with pedicle flaps or alternative donor sites were excluded. Patient demographics, medical/surgical history, cancer treatments, and flap type were analyzed. All patients were monitored for a minimum of 2 years for early donor site complications as well as hernia/bulges.

RESULTS

Sixty-six consecutive patients were included (40 patients with Phasix, 20 patients with polypropylene, and 6 patients with primary closure). Use of Phasix mesh resulted in higher initial operative costs ($2,750 vs. $72 vs. $0). Two patients with polypropylene mesh and one patient undergoing primary closure developed an abdominal bulge in an average follow-up of 25.2 months (11.5% vs. 0%, p = .04).

CONCLUSIONS

Mesh placement for abdominal wall reinforcement after bilateral free flap breast reconstruction minimizes the risk of hernias and bulges. Although Phasix results in increased initial costs, abdominal morbidity is significantly decreased after follow-up beyond 2 years.